Using Modifier 24: Understand the Rules of the Game

Using Modifier 24: Understand the Rules of the Game

Appending modifiers on a claim form is like playing Monopoly. Use the right modifier in the right situation, and it is like "passing go," and collecting $200. The claim sails through the claims processing system on the first pass, and the insurance company deposits money in the practice's account. However, use modifiers incorrectly, and you will receive payment denials or worse. Not unlike picking a "Go to Jail card," incorrect modifier use puts your practice at risk for a payer request for a refund.

Modifier 24 is appended to an evaluation and management service (never to a procedure) to indicate that an unrelated E&M service was provided by the same physician during a postoperative period. Other, "same-specialty physicians" are included in the definition of "same physician." That is, if a surgeon is covering post-op patients for her partner, the covering surgeon is considered the same physician and does not bill for it. Remember, modifier 24 is used for an unrelated E&M service.

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The following are three examples where you could use modifier 24:

• A surgeon performs a hernia repair on May 20. The procedure has a 90-day global period, so all related post-op care is included in the payment for the hernia. But, on July 1, the patient returns to have a breast lump evaluated. Report the E&M service with modifier 24 attached and use the new diagnosis — breast lump — as the reason for the visit.

•An orthopedist treats a hip fracture on Dec. 15, and the patient returns with shoulder pain on Jan. 10. The Jan. 10 visit is separately reportable with modifier 24.

• A surgeon who is managing immunosuppressant therapy during a post-op period for a transplant may use also modifier 24 for the E&M services and be paid separately for these.

The Medicare and CPT definition of the post-op global package are slightly different. Medicare states that unless a return trip to the operating room is required, all medical and surgical post-op complications are included in the global payment and may not be separately billed. Also treatment of wound infections or other complications may not be reported to Medicare.

However, the CPT definition of the surgical package is "typical" post-op care. This is found in the introductory material to the surgical section in the CPT book. This raises a question: If a payer follows CPT rules and not Medicare rules, can a surgeon report atypical post-op care for complications? Yes. How? Some practices use modifier 24 in this instance for E&M services for medical complications. Use the complication diagnosis code first on the claim form. However, it is critical that you check with your payer to be sure this follows its rules, because the definition of modifier 24, as developed by the AMA, is for unrelated care.

Other physicians who see the patient during the global period do not need to use modifier 24. If a patient in a surgical post-op period sees an internist, the internist does need to append a modifier to the E&M service. Only the operating physician, and his or her same-specialty partners or covering surgeons, need to use modifier 24.

Review the official definition of each modifier in the CPT book annually. It provides the definitive answers to your questions, so that applying a modifier goes from a game of chance to a sure thing.

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